This entry is our analysis of a study added to the Effectiveness Bank. The original study was not published by Findings; click Title to order a copy. Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text The Summary conveys the findings and views expressed in the study. Below is a commentary from Drug and Alcohol Findings.

National Treatment Agency for Substance Misuse.[UK] National Treatment Agency for Substance Misuse, 2010.

Support for the argument made by England's National Treatment Agency for Substance Misuse that relapse is less likely if patients leave treatment after having successfully completed the programme rather than dropping out – but maybe staying in treatment for at least a few years is even better.

The agency's argument that increasing numbers of successful completions means increasingly successful treatment rests partly on this analysis of 41,475 patients leaving treatment for drug problems in England in financial year 2005/06. They were among the just over 54,000 who left that year for reasons other than being imprisoned and who could be identified as unique individuals.

At issue was whether having left in 2005/06, over the next four years through to the end of 2009/10 there was evidence of treatment failure and continuing illegal drug use or relapse. For the study this evidence took the form of a return to treatment recorded by the National Drug Treatment Monitoring System, and/or the individual appearing in criminal justice records relating to testing for drug use after arrest and/or the programme intended to identify offenders in need of addiction treatment. Though not a guarantee of success, former patients who did not (re)appear in these records were likely to be treatment successes who had overcome their dependence and stayed out of drug-related trouble.

In turn this evidence of treatment failure or success was related to whether the patient had been recorded as leaving treatment after having 'successfully completed' the programme. As reported by the treatment service from which the patient last exits, this means they are no longer seen as requiring structured drug treatment, and have left treatment (not just that service, but the system as a whole) no longer dependent on any drug and not using opiates or crack cocaine (12).

Main findings

Over the next four years 46% of 2005/06 treatment leavers avoided being officially recorded as problematic users of illegal drugs, neither being picked up by criminal justice system nets nor returning to treatment on their own initiative. Of the remainder, 83% (amounting to 45% of all treatment leavers) returned to treatment. Of these treatment returners, 38% re-arrived via criminal justice routes.

The chances of an apparently lasting recovery from dependence on illegal drugs were greater among the 9770 patients – roughly a quarter of all treatment leavers – who left treatment after having successfully completed. Of these, 57% avoided later being officially recorded as problem users of illegal drugs compared to 43% of patients who left without having successfully completed. Not just successfully completing treatment, but also being recorded at treatment exit as entirely free of illegal drug use, did not further improve the apparent recovery rate.

Of users of the different types of drugs, at 66% the apparent recovery rate was highest among patients treated for problems other than dependence on crack or opiates like heroin. For example, 69% treated for cannabis problems and 64% for powder cocaine did not reappear in the records. At the other extreme, only 28% of patients dependent on both opiates and crack cocaine avoided being re-recorded. Not far behind (37%) were the opiate-only users and then (49%) those using only crack. Taking all these opiate and crack users together, 36% apparently experienced lasting recovery. Due largely to the opiate users among them, patients aged 40 or over at treatment exit were most likely to avoid being re-recorded, having apparently ended their addiction careers.

If patients were to be re-recorded, generally (57% those re-recorded) this happened within a year, steeply tailing off after that, and more quickly (59% in a year versus 47% for completers) among patients who had not successfully completed treatment.

The authors' conclusions

Of patients exiting treatment in 2005/06, it can be presumed that most of the 46% who did not return to treatment or get identified as problem users by criminal justice agencies had sustained their recovery from addiction. On this yardstick, lasting recovery was least likely among patients being treated for problems with both opiates and crack cocaine. Successfully completing treatment was an indicator of a good long-term outcome, but many (up to 43%) who left after having dropped out or for some other reason appear nevertheless to have benefited and overcome dependence, corroborating what some practitioners have argued: that although drop-out usually means relapse, some simply walk away from treatment once it has met their clinical needs.

commentary The difference of 14% in the apparent long-term recovery rate between 'successful' treatment completers and 'drop-outs' is appreciable, but not as large as would be expected if successful completion was a reliable indicator that treatment really had been successful in promoting lasting recovery. Nevertheless, it is enough to justify basing practice on the assumption that successful completion is a better outcome than patients leaving treatment before the service considers them free of dependence and/or use of heroin or crack cocaine.

In terms of reduced convictions and presumably reduced crimes, another report from the National Treatment Agency for Substance Misuse supports this conclusion. It was concerned with the 19,570 of the 53,851 adults (re)starting treatment in England in 2006/07 who had been convicted for one or more drug-related offences committed in the previous two years, and who were either absent from or could reliably be matched to police records. In the next two years the conviction rate fell by 41% among the patients who (as assessed by their treatment service) had left treatment free of dependence, of the need for addiction treatment, and of opiate and crack cocaine use – the criteria for successful completion – a much better record than the 15% among treatment 'drop-outs'. The drop-outs were much more likely to have to return to treatment within the two years (63% v. 42%) and among those who did return, the conviction rate had barely dropped at all, by just 5%.

These reports spotlight successful treatment completers as best exemplifying the success of the treatment system in fostering recovery. Such patients are however the minority in any year. In 2010/11, they represented about 14% of all patients in treatment that year for problems involving illegal drugs. Far more common (68% in 2010/11) is for patients to still be in treatment at the end of any given year, and to remain in treatment contact over several years. For example, of patients in treatment in 2005/06, 57% were also in treatment at the end of 2010/11, and of these, 43% had remained continuously in treatment.

Though successful completion means a better prognosis than drop-out, it is by no means clear that is better than staying in treatment. The report cited above recorded its greatest reductions in convictions (down 47%) among patients continuously in treatment for the next two years after (re)starting in 2006/07, even better than the 41% among successful treatment leavers. When the focus was narrowed to opiate/crack users, among whom successful completers and retained patients had a virtually identical pre-treatment conviction rate, the gap in favour of retained patients widened to 10% (46% v. 36%). With both greater numbers and a better record, rather than leaving after apparent success, staying in treatment was the main way both the patients and the wider society were protected from continuing crime.